11. Glomerular Pathology

Question 1

Where is the likely site of injury in proteinuria/nephrotic syndrome?

Answer 1

Podocyte or subepithelial damage.

Question 2

What are the 3 most common primary causes of proteinuria/nephrotic syndrome?

Answer 2

Minimal change glomerulonephritis.
Focal segmental glomerulosclerosis.
Membranous glomerulonephritis.

Question 3

Name 1 common secondary cause of proteinuria/nephrotic syndrome?

Answer 3

Diabetes mellitus.

Amyloidosis.

Question 4

Which age group is minimal change glomerulonephritis most common in?

Answer 4

Childhood/adolescence.

Question 5

What treatment does minimal change glomerulonephritis respond to?

Answer 5

Steroids (but may recur when steroids stopped).

Question 6

Does minimal change glomerulonephritis usually progress to renal failure?

Answer 6

No, does not usually progress to renal failure.

Question 7

How does the glomerulus look histologically in minimal change glomerulonephritis?

Answer 7

Glomerulus looks normal, but there are no podocytes visible as they have been damaged (cannot selectively filter proteins anymore).

Question 8

What causes podocyte damage in minimal change glomerulonephritis?

Answer 8

An unknown circulating factor damages the podocytes. There is no immune complex deposition.

Question 9

In which age group is focal segmental glomerulosclerosis more common?

Answer 9

Adults.

Question 10

What causes podocyte damage in focal segmental glomerulosclerosis and what consequence does this have for treatment?

Answer 10

Circulating factor damages podocytes. FSGS is progressive to renal failure, but if the patient has a kidney transplant, the transplanted kidney will also get FSGS due to the circulating factors. So treatment is with dialysis rather than transplant.

Question 11

Which age group if membranous glomerulonephritis most common in?

Answer 11

Adults.

Question 12

How does membranous glomerulonephritis typically progress?

Answer 12

1/3 patients get better.
1/3 patients continue as they are.
1/3 patients progress to renal failure.

Question 13

What causes podocyte damage in membranous glomerulonephritis?

Answer 13

Immune complex deposits against the podocytes - sub-epithelial deposits (so is probably autoimmune).

Question 14

Is membranous glomerulonephritis primary or secondary?

Answer 14

Is primary but may be secondary as has been associated with other pathologies eg lymphoma.

Question 15

What is seen histologically in patients with diabetes mellitus leading to nephrotic syndrome?

Answer 15

Mesangial sclerosis leading to nodules.

Basement membrane thickening.

Question 16

Does nephrotic syndrome secondary to diabetes mellitus progress to renal failure?

Answer 16

Yes - progressive proteinuria and is progressive to renal failure.

Question 17

What are the two most common causes of haematuria?

Answer 17

IgA nephropathy.

Thin glomerular basement membrane disease/hereditary nephropathy (Alport).

Question 18

What are the two most common causes of nephritic syndrome?

Answer 18

Goodpasture syndrome (anti-GBM disease).
Vasculitis.

Question 19

In which age group os IgA nephropathy most common?

Answer 19

Any age group.

Question 20

What type of infections is IgA nephropathy associated with?

Answer 20

Mucosal infections - viral upper respiratory tract eg common cold.

Question 21

Does IgA nephropathy present with proteinuria?

Answer 21

It can present with or without proteinuria.

Question 22

Does IgA nephropathy progress to renal failure?

Answer 22

A significant proportion progress to renal failure.

Question 23

How would you treat a patient with IgA nephropathy?

Answer 23

There is no effective treatment.

Question 24

What is mesangial damage? Why does this occur and how does this lead to haematuria.

Answer 24

Loss of mesangial cells in the glomerulus.
Immune complexes (IgA) pass though the glomerulus to the mesangial cells causing damage.
Capillary loop becomes fragile, leading to haematuria.

Question 25

Name 2 heredity nephropathies that do not progress to renal failure.

Answer 25

Thin GBM nephropathy.
Benign familial nephropathy.
Isolated haematuria.
Thin GBM.

Question 26

Name 2 hereditary nephropathies that can progress to renal failure.

Answer 26

Alport.
X linked.
Abnormal collagen IV.
Associated with deafness.
Abnormal appearing GBM.

Question 27

Are hereditary nephropathies as clear cut as either progressive to renal failure or not progressive?

Answer 27

No, often a grey area of patients between the two types of conditions, likely to be because multiple genes make up the conditions.

Question 28

What is seen histologically in the glomerulus of patients with Alport’s syndrome?

Answer 28

Abnormally split and laminated GBM.

Question 29

Does goodpasture syndrome (anti-GBM) progress to renal failure?

Answer 29

Yes, is very rapidly progressive.

Question 30

How does goodpasture syndrome usually present?

Answer 30

Acute onset of severe nephritic syndrome, classically associated with pulmonary haemorrhage (smokers).

Question 31

What causes GBM damage in goodpasture syndrome?

Answer 31

Autoantibody to collage IV in basement membrane. IgG deposition, inflammation and necrosis, filter blocked, becomes nephritic and blood leaks out.

Question 32

How would you treat goodpasture syndrome if it is caught early?

Answer 32

Immunosuppresion and plasmaphoresis.

Question 33

What causes GBM damage in vasculitis?

Answer 33

Anti neutrophil cytoplasmic antibodies and neutrophils cause segmental necrosis by activating complement and so punching out holes in the GBM - endothelial damage.

Question 34

Is there immune complex/antibody deposition in vasculitis?

Answer 34

No - circulating antibodies to white cells.

Question 35

Is vasculitis treatable? What do you need to do urgently if you suspect a patient has vasculitis?

Answer 35

Only if caught early.

Urgent biopsy.

Question 36

How do patients with nephritic syndrome tend to present?

Answer 36

Hypertension.
Haematuria.
Oliguria.
Glomerular inflammation and reduction in GFR.

Question 37

How do patients with nephrotic syndrome tend to present?

Answer 37

Hypoalbuminemia.
Hyperlipidaemia.
Proteinuria.
Peripheral oedema.

Question 38

What conditions can present as either nephritic or nephrotic syndrome?

Answer 38

IgA purpura.
Post-infectious.
Lupus.

Question 39

How do patients with vasculitis tend to present?

Answer 39

Systemic symptoms - lungs affected (pulmonary-renal syndrome), fatigue, arthralgia, myalgia, weight loss.